Name (*First Name, MI, *Last Name)

Home Address

* City

* State

Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AAArmed Forces AEArmed Forces AP

* Zip Code

Phone

(Please do not include spacing. Example: 5555555555)

* Email

(Example: janedoe@gmail.com)

*How would you like to get involved? (Select all that apply)

Board Member - the opportunity to participate in the governance of the organization as well as donate or help raise $10,000 per year.

Committee Member - the opportunity to help plan the annual gala as well as donate or help raise $1,000 per year.

Donor - the opportunity to donate money, products or services to an organization to help it further its mission.

Other

*Have you ever done fundraising in the past?

Yes
No

*If yes, how much have you raised?

Select one.. 0-$999 $1,000-4,999 $5,000-9,999 $10,000-49,999

*I am passionate about being involved in (Select all that apply) :

Infant Mortality

Brain Cancer

Cerebral Palsy

Lyme Disease

Sarcoma

Melanoma /Skin Cancer

International Human Rights Through Photojournalism

Current Employment Information

Job Title

Company Name

How did you hear about us? :

Advertisement

Referral

Search Engine

Website

Other